WHO Technical Briefing: Health Intervention and Technology Assessment | May 23, 2014 1 |1 | Priority Setting in Universal Health Coverage The role of Health

WHO Technical Briefing: Health Intervention and Technology

Assessment | May 23, 20141 |

Priority Setting in Universal Health Coverage

The role of Health Intervention & Technology Assessment

Priority Setting in Universal Health Coverage

The role of Health Intervention & Technology Assessment

Dr. Kees de JoncheereDirector EMP department

EMP Technical Briefing Seminar, November 2014

Dr. Kees de JoncheereDirector EMP department

EMP Technical Briefing Seminar, November 2014



OutlineOutline

• Concept of UHC and Priority Setting

• What is Health Intervention and Technology Assessment

• Ongoing programmes of work contributing to HITA in WHO

• HTA for medicines evaluation

• The way forward



Universal health coverage (UHC)Universal health coverage (UHC)

The goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.

– A strong, efficient, well-run health system that meets priority health needs

– Affordability – a financing system to avoid financial hardship

– Access to essential medicines and other health technologies

– Sufficient capacity of well-trained, motivated health workers to provide the services needed

Resources are scarce in all settings and forms of priority setting are inevitable

EVANS, David B.

the bullet you had prejudges the next slide, so I prefer to keep it general here



Three Dimensions to Consider When Moving Towards Universal Coverage



Considerations in priority settingConsiderations in priority setting

In moving towards UHC, questions focus on:– The population covered by the package of interventions: Who ?– The services that can be provided: Which services ?– The proportion of service costs that can be covered: How much ?

Health technology assessment (HITA) is an important process to aid priority-setting within the services axis of the UHC cube



What is Health Intervention & Technology Assessment?

What is Health Intervention & Technology Assessment?

Health technology is the application of organized knowledge and skills in the form of interventions, devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives

Technology assessment in health care is a multidisciplinary field of policy analysis. It studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology.

HITA does not make the decisions, however the systematic assessment of the evidence makes the trade-offs between alternative actions clear



The continuum of HITA activitiesThe continuum of HITA activities

Health

System

s

Continuum of HTA Activities



Uses of HITA methods in WHO Uses of HITA methods in WHO

WHO Model List of Essential Medicines

Package of Essential Noncommunicable (PEN) disease interventions for primary health care, 'best buys' for NCDs

WHO-CHOICE, CHOosing Interventions that are Cost Effective global database of around 500 health technologies

OneHealth Tool designed to inform national strategic health planning in low- and middle-income countries.

Assessing medical devices and assistive devices for an ageing population



Examples of ongoing HITA in WHOExamples of ongoing HITA in WHO

WHO Model List of Essential Medicines– First published in 1977– Updated every 2 years– 156 countries have essential medicines lists

OneHealth Tool for Costing and Strategic planning– Development began in 2008 – Released in 2012– Has to date been used in over 25 countries

WHO-CHOICE – Ongoing since 1998– Development of cost-effectiveness analyses of interventions covering all

WHO regions



WHO-CHOICE example resultsWHO-CHOICE example results



What is needed for HITA?What is needed for HITA?

Assessment is based on collecting, evaluating, and systematically reviewing all available evidence for the intervention or technology being considered

– Types of data include epidemiological, economic, health impact, expert opinion– Methods include assessing the quality of available information, systematic review

and meta-analysis, surveys, feasibility, affordability and ethical considerations

Multidisciplinary skills are needed to assemble and interpret the data

Countries with the greatest need often have the least capacity

Different types of HITA vary in scope, time and resources required– Full scale health technology assessment report– Contextualization of reports produced by others



Evaluation of new medicines Evaluation of new medicines

For market entry : – quality, efficacy, safety ; benefit/risk assessment

For reimbursement– Medical need and severity of disease– Health gain and added therapeutic value– Availability of alternatives– Cost-effectiveness– Budget impact– Equity considerations– …



Evaluation of new medicines Evaluation of new medicines

For medical practice

– Evaluation by drug bulletins, professional associations on the “place in therapy” of a new medicine

– Consistency between reimbursement indications and therapeutic guidelines ?

– Reviews by national HTA bodies



Implications of cost-effectiveness analysis for reimbursement

Implications of cost-effectiveness analysis for reimbursement

Health-based reason to justify a price premium for the proposed drug

Relate extent and nature of health gain to justify price increase, including cost off-sets in health sector

Common outcome measure (QALY, life year gained,.. )

Pristine value judgement



Economic evaluations Economic evaluations

Two main approaches

– on a “cost-minimisation” basis

– as “acceptably cost-effective”

Two main “levers”

– restrict to particular patients

– price of the proposed drug



Reimbursement decision-making process : after the initial reimbursement decision …

Reimbursement decision-making process : after the initial reimbursement decision …

Post-listing reviews (at least annually)

– prices

– restrictions and listings

Post-listing monitoring (at least annually)

– usage (including predicted versus actual)

– cost to reimbursement system

Coordinate post-listing activities



International collaboration on evaluation of medicinesInternational collaboration on evaluation of medicines

Health care systems are different

Issues tend to be the same : costs drivers and evidence

Basis for common guidance, and exchange of information, and “lessons learned” ? !

– MEDEV

– EU network of Pricing and Reimbursement authorities

– EUnetHTA

– INAHTA, ISPOR, HTAi

– HiTAP and South East Asia network

– REDETSA Latin America network

– PPRI and PHIS networks



Making cost-effectiveness evaluations work (1)

( do countries have the resources to do this ?)Making cost-effectiveness evaluations work (1)

( do countries have the resources to do this ?) Separate licensing and reimbursement decisions

Positive list

Price negotiations

Ability to restrict indications

Adequate guidelines for submissions

Competent evaluations of submissions

Consistent and informed decision-maker



Making cost-effectiveness evaluations work : decision-making process (2)

Making cost-effectiveness evaluations work : decision-making process (2)

Inclusiveness in decision-making and input from all stakeholders

Reimbursement committees with external experts : managing potential conflict-of-interests

Health Technology Assessment agencies and committees often not directly linked with reimbursement decisions



Use of cost-effectiveness analysis in reimbursement

Use of cost-effectiveness analysis in reimbursement

Growing requirements and increasing need for resources

“Silo-budgeting” limits application

Shift to “risk-sharing” with patient registries : from paying for the medicine to buying an agreed upon therapeutic outcome

CEA needs to relate to goals, values, and priorities of the health care systems

RCTs do not provide all information needed : discuss with industry the need for additional trials

How to deal with “point-decisions” vis-à-vis re-assessment of the evidence ?

Discussions on appropriateness of QALY`s

Discussions on thresholds



The way forwardThe way forward

WHO HQ plans to undertake a global mapping survey of current capacity and perceived needs for HITA in member states

A focus of moving forward should be on

– Advocacy and promotion of priority setting (including HITA) best practices – Facilitate sharing of technology assessment and experiences among countries

including through the development of platforms for information exchange– Capacity building activities including networks where appropriate

Documents

WHO Technical Briefing: Health Intervention and Technology Assessment | May 23, 2014 1 |1 | Priority Setting in Universal Health Coverage The role of Health